Geriatric assessment and treatment outcomes in a Dutch cohort of older patients with potentially curable esophageal cancer

Background Patients with potentially curable esophageal cancer can be treated with neo-adjuvant chemoradiotherapy followed by surgery or definitive chemoradiotherapy with curative intent. For frail older patients choosing the appropriate oncological treatment can be difficult, and data on geriatric deficits as determinants of treatment outcomes are not yet available. Objectives To describe the prevalence of geriatric deficits and to study their association with treatment discontinuation and mortality in older patients with potentially curable esophageal cancer. Material and Methods A cohort study was conducted in a Dutch tertiary care hospital including patients aged >= 70 years with primary stage I-IVA esophageal cancer. Geriatric screening and assessment data were collected. Outcomes were treatment discontinuation and one year all-cause mortality. Results In total, 138 patients with curable esophageal cancer were included. Mean age was 76.1 years (standard deviation 4.7), 54% had clinical stage III and 24% stage IVA disease. Most patients received neo-adjuvant chemoradiotherapy and surgery (41%), 32% definitive chemoradiotherapy and 22% palliative radiotherapy. Overall, one year all-cause mortality was 36%. Geriatric screening and assessment was performed in 94 out of 138 patients, of which 60% was malnourished, 20% dependent in Instrumental Activities of Daily Living (IADL) and 52% was frail. Malnutrition was associated with higher mortality risk (Hazard Ratio, 3.2; 95% Confidence Interval, 1.3-7.7)) independent of age, sex and tumor stage. Seventy-six out of 94 patients were treated with chemoradiotherapy, of which 23% discontinued treatment. Patients with IADL dependency and Charlson Comorbidity Index >= 1 discontinued treatment more often. Conclusion All-cause mortality within one year was high, irrespective of treatment modality. Treatment discontinuation rate was high, especially in patients treated with definitive chemoradiotherapy. Geriatric assessment associates with outcomes in older patients with esophageal cancer and may inform treatment decisions and optimization in future patients, but more research is needed to establish its predictive value.Cellular mechanisms in basic and clinical gastroenterology and hepatolog

A prospective, randomized placebo-controlled clinical trial on the effects of a fluoride rinse on white spot lesion development and bleeding in orthodontic patients

Demineralizations around orthodontic brackets are a main disadvantage of orthodontic treatment. Several methods have been advocated to prevent their development, such as fluoride rinses or varnishes. In this randomized clinical trial, a fluoride rinse (a combination of sodium fluoride and amine fluoride) was compared with a placebo rinse, to be used every evening after toothbrushing. A total of 81 participants (mean age: 13.3 yr) completed the study (mean treatment period: 24.5 months). Demineralizations, measured using quantitative light‐induced fluorescence and the decayed, missing, and filled surfaces (DMFS) index, were assessed before treatment (baseline) and around 6 wk after debonding (post treatment). Bleeding scores were measured at baseline, and during and post treatment. The incidence rate ratio for demineralizations was 2.6 (95% CI: 1.1–6.3) in the placebo group vs. the fluoride group. In the fluoride group, 31% of participants developed at least one demineralization, compared with 47% in the placebo group. Relative to baseline, gingival bleeding increased significantly in the placebo group 1 yr after the start of treatment and onwards. For the fluoride group, bleeding scores during treatment were not different from those at baseline. In conclusion, using a fluoride rinse helps to maintain better oral health during fixed appliance treatment, resulting in fewer demineralizations

Sexual dysfunction and infertility as late effects of cancer treatment

Sexual dysfunction is a common consequence of cancer treatment, affecting at least half of men and women treated for pelvic malignancies and over a quarter of people with other types of cancer. Problems are usually linked to damage to nerves, blood vessels, and hormones that underlie normal sexual function. Sexual dysfunction also may be associated with depression, anxiety, relationship conflict, and loss of self-esteem. Innovations in cancer treatment such as robotic surgery or more targeted radiation therapy have not had the anticipated result of reducing sexual dysfunction. Some new and effective cancer treatments, including aromatase inhibitors for breast cancer or chemoradiation for anal cancer also have very severe sexual morbidity. Cancer-related infertility is an issue for younger patients, who comprise a much smaller percentage of total cancer survivors. However, the long-term emotional impact of being unable to have a child after cancer can be extremely distressing. Advances in knowledge about how cancer treatments may damage fertility, as well as newer techniques to preserve fertility, offer hope to patients who have not completed their childbearing at cancer diagnosis. Unfortunately, surveys in industrialised nations confirm that many cancer patients are still not informed about potential changes to their sexual function or fertility, and all modalities of fertility preservation remain underutilised. After cancer treatment, many patients continue to have unmet needs for information about restoring sexual function or becoming a parent. Although more research is needed on optimal clinical practice, current studies suggest a multidisciplinary approach, including both medical and psychosocial treatment options

Geriatric characteristics and the risk of drug-related hospital admissions in older Emergency Department patients

Key summary pointsAim To investigate (a) the prevalence and clinical manifestations of Drug-Related Admissions (DRAs) and the drugs responsible for these admissions, (b) to study the association between geriatric characteristics and DRAs and c) to study the predictive performance of geriatric screening instrument for identifying DRAs in older patients presenting to the Emergency Department (ED). Findings DRAs are prevalent in older hospitalized patients. Polypharmacy, ADL dependency and a high ISAR or ISAR-HP score are associated with higher risk for a DRA, but the predictive value of geriatric screeners is insufficient and therefore they cannot be used alone to predict for Drug-Related Hospital Admissions in Emergency Department. Message Geriatric screening instruments are not specific and sensitive enough to use alone for identifying drug-related hospital admissions in older patients in the ED.Purpose Drug-Related Admissions (DRAs) are a well-known problem among older patients in the Emergency Department (ED). The aim of this study was (a) to investigate the prevalence and clinical manifestations of DRAs and the responsible drugs, (b) to study the association between geriatric characteristics and DRAs, and (c) to study the predictive performance of geriatric screeners for identifying DRAs in older ED patients. Methods Patients aged >= 70 hospitalized from the ED were included. Demographics, geriatric characteristics and medications were collected. The the Acutely Presenting Older Patient (APOP)-screener, the Identification of Seniors At Risk (ISAR) and the ISAR-Hospitalized Patients (ISAR-HP) were used as geriatric screeners. Potential DRAs were identified retrospectively, the association between geriatric screeners and DRAs was investigated with logistic regression and the predictive performance was assessed by calculating the Area under the Curve (AUC) of the Receiver Operator Characteristics (ROC). Results The mean age of patients was 78 (IQR 73-83), using an average of 6 medications. Out of 240 admissions, 77 (30%) were classified as a DRA. Independent risk factors for DRAs were polypharmacy (OR 2.42; 95% CI 1.23-4.74) and the ADL dependency (OR 1.23; 95%CI 1.05-1.44). ISAR (OR 3.27; 95%CI 1.60-6.69) and ISAR-HP (OR 1.83; 95% CI 1.02-3.27) associated with increased risk of DRAs, whereas the APOP screener did not (OR 1.56; 95% CI 0.82-2.97). The predictive performance of all geriatric screeners for predicting DRAs was poor (AUC for all screeners < 0.60). Conclusion DRAs are highly prevalent in older ED patients. Polypharmacy, ADL dependency and a high ISAR or ISAR-HP are associated with higher risk for DRAs, but the predictive value of geriatric screeners is insufficient.Clinical Pharmacy and Toxicolog

Cryopreservation, semen use and the likelihood of fatherhood in male Hodgkin lymphoma survivors: An EORTC-GELA lymphoma group cohort study

STUDY QUESTIONHow does the successful cryopreservation of semen affect the odds of post-treatment fatherhood among Hodgkin lymphoma (HL) survivors?SUMMARY ANSWERAmong 334 survivors who wanted to have children, the availability of cryopreserved semen doubled the odds of post-treatment fatherhood.WHAT IS KNOWN ALREADYCryopreservation of semen is the easiest, safest and most accessible way to safeguard fertility in male patients facing cancer treatment. Little is known about what proportion of patients achieve successful semen cryopreservation. To our knowledge, neither the factors which influence the occurrence of semen cryopreservation nor the rates of fatherhood after semen has been cryopreserved have been analysed before.STUDY DESIGN, SIZE, DURATIONThis is a cohort study with nested case-control analyses of consecutive Hodgkin survivors treated between 1974 and 2004 in multi-centre randomized controlled trials. A written questionnaire was developed and sent to 1849 male survivors.PARTICIPANTS/ MATERIALS, SETTING, METHODSNine hundred and two survivors provided analysable answers. The median age at treatment was 31 years. The median follow-up after cryopreservation was 13 years (range 5-36).MAIN RESULTS AND THE ROLE OF CHANCEThree hundred and sixty-three out of 902 men (40%) cryopreserved semen before the start of potentially gonadotoxic treatment. The likelihood of semen cryopreservation was influenced by age, treatment period, disease stage, treatment modality and education level. Seventy eight of 363 men (21%) used their cryopreserved semen. Men treated between 1994 and 2004 had significantly lower odds of cryopreserved semen use compared with those treated earlier, whereas alkylating or second-line (chemo)therapy significantly increased the odds of use; no other influencing factors were identified. We found an adjusted odds ratio of 2.03 (95% confidence interval 1.11-3.73, P = 0.02) for post-treatment fatherhood if semen cryopreservation was performed. Forty-eight out of 258 men (19%) who had children after HL treatment became a father using cryopreserved semen.LIMITATIONS, REASONS FOR CAUTIONData came from questionnaires and so this study potentially suffers from response bias. We could not perform an analysis with correction for duration of follow-up or provide an actuarial use rate due to lack of dates of semen utilization. We do not have detailed information on either the techniques used in cryopreserved semen utilization or the number of cycles needed. © 2013 The Author

Premature ovarian failure and fertility in long-term survivors of Hodgkin's lymphoma: A European Organisation for Research and Treatment of Cancer Lymphoma Group and Groupe d'ÉTude des Lymphomes de l'Adulte Cohort Study

Purpose: In this large cohort of Hodgkin's lymphoma survivors with long follow-up, we estimated the impact of treatment regimens on premature ovarian failure (POF) occurrence and motherhood, including safety of nonalkylating chemotherapy and dose-response relationships for alkylating chemotherapy and age at treatment. Patients and Methods: The Life Situation Questionnaire was sent to 1,700 women treated in European Organisation for Research and Treatment of Cancer and Groupe d'Étude des Lymphomes de l'Adulte trials between 1964 and 2004. Women treated between ages 15 and 40 years and currently not using hormonal contraceptives (n = 460) were selected to assess occurrence of POF. Cumulative POF risk was estimated using the life-table method. Predictive factors were assessed by Cox regression analysis. Results: Median follow-up was 16 years (range, 5 to 45 years). Cumulative risk of POF after alkylating chemotherapy was 60% (95% CI, 41% to 79%) and only 3% (95% CI, 1% to 7%) after nonalkylating chemotherapy (doxorubicin, bleomycin, vinblastine, and dacarbazine; epirubicin, bleomycin, vinblastine, and prednisone). Dose relationship between alkylating chemotherapy and POF occurrence was linear. POF risk increased by 23% per year of age at treatment. In women treated without alkylating chemotherapy at age younger than 32 years and age 32 years or older, cumulative POF risks were 3% (95% CI, 1% to 16%) and 9% (95% CI, 4% to 18%), respectively. If menstruation returned after treatment, cumulative POF risk was independent of age at treatment. Among women who ultimately developed POF, 22% had one or more children after treatment, compared with 41% of women without POF. Conclusion: Nonalkylating chemotherapy carries little to no excess risk of POF. Dose-response relationships for alkylating chemotherapy and age at treatment are both linear. Timely family planning is important for women at risk of POF